ELLSWORTH — For more than 50 years, Americans have taken it as a given that when they call 911, an ambulance will come to the rescue.
The ride may be expensive and the hospital far, but the expectation for the better part of a century has been that an ambulance will be there.
In many areas of the country, however, this lifeline is threatened.
“I’m really worried that we’re approaching that time when somebody calls 911 and there’s not an ambulance to respond,” said Rick Petrie, director of Winslow-based Atlantic Partners EMS, a nonprofit organization responsible for training and advocacy.
The problem can be particularly acute in rural areas, where populations are dwindling and aging residents require more care.
The issues facing emergency services in rural areas are numerous and complicated, Petrie said.
To start, it’s difficult to recruit for a job with long, often unpredictable hours, many of which are spent waiting around.
Pay is generally low, with basic emergency medical technicians starting at minimum wage or just above (after 37 years in the business, Petrie was a paramedic making $23.50 an hour).
The work is physically and emotionally taxing. Rigs are often old and roads bumpy. Education can be pricey. Most services rely on reimbursement from insurers, Medicare and MaineCare to stay afloat, but reimbursement rates are often a fraction of what it costs to provide the service.
Many of the issues, Petrie said, can be traced back to underfunding.
Government payers (Medicare and MaineCare) have fixed reimbursement rates based on the type of procedure. No matter what it costs to go on a call, they will pay only a percentage of the bill.
“MaineCare pays about 40 percent of our costs for an ambulance trip,” said Joe Kellner, vice president of emergency services and community programs at Northern Light Emergency Medical Transport. “Medicare is about 85 percent,” and is often used as a benchmark for other insurers. “Covering the costs is really what is pushing ambulance services to the brink across the state.”
Ambulance crews are not reimbursed for calls unless they transport a patient. They can’t bill for other aspects of running a business, such as vehicle maintenance, supplies or education.
Services owned by larger companies, such as the four under the Northern Light umbrella, are often able to offer better benefits than smaller companies, said Kellner, but are still expected to be financially solvent.
“Payment reimbursement goes up roughly 1 percent per year, but expenses go up by 3 percent a year,” Kellner said. “It’s really not hard to do the math.”
The price of medications often fluctuates as well, said Kellner, giving the example of the EpiPen, which went from a few cents apiece several years ago to more than $11 today.
So those are the problems. What about solutions?
One is to increase volume. Services that take more calls are able to come closer to breaking even, which also allows for a more consistent schedule and helps avoid provider overtime and burnout.
Kellner said most services need to take between 1,800 and 2,000 calls to be financially viable. But 80 percent of ambulance companies in Maine respond to fewer calls than that, Petrie said.
Consolidating services could help make providing care more efficient, he continued, although it might be unpopular.
“We have to be willing to look at whether an ambulance service doing 250 or 300 calls a year is appropriate.”
There is also the option of mutual aid contracts, said Kellner, which can help alleviate pressure on a single service. Some cities around the country offer subsidies or engage in a public-private partnership, such as the trial one between Ellsworth and Northern Light.
Services with robust volunteer programs also can do well, although many emergency service providers say volunteerism is declining, in part because it is increasingly difficult to find employers willing to let their personnel off for hours during the workday.
Volunteers are what keep the Schoodic EMS system viable, said Fire Chief Tate McLean.
Schoodic EMS formed after County Ambulance closed its doors last August, leaving many towns scrambling to find coverage. Some signed contracts with Northern Light or Blue Hill-based Peninsula Ambulance Corps, but Winter Harbor and Gouldsboro decided to “take care of our own,” McLean said.
With Northern Light’s primary focus area in Ellsworth, said McLean, he worried that response times could increase dramatically in other towns if Northern Light was tied up elsewhere.
Besides, McLean said, the department already had several volunteers licensed as emergency service providers, some supplies and two donated ambulances.
“We pretty much had everything in place.”
“For right now, it’s tax-based, but hopefully within five years it’ll be self-supporting,” McLean said.
Another challenge facing the industry is the mental health risk. The suicide rate among first responders is already several times higher than that among the general public and has been increasing in recent years.
“Young people realize that they can become a computer programmer or a plumber or an electrician and not work in the conditions that EMS providers work in and make more money,” Petrie said.
“If McDonald’s ever starts paying $15 an hour,” he continued, “we’re in trouble.”